The growing area of military bio-technologies, especially the use of cogniceuticals, raises several ethical concerns for military physicians. These include the role of military physicians in prescr...

It is an imperative within health care, medicine, and public health to restore, preserve, and enhance health. Therefore, it is important to determine what kinds of enhancement are increases in health and what kinds are not. Taking as its point of departure two conceptions of health, namely, “manifest health” and “fundamental health,” the paper discusses various means used to enhance ability and well-being, and if those means, such as wheelchairs, implants, medicines, stimulants, or narcotics, enhance health. The fact that some (...) means that enhance ability or well-being are not usually considered health enhancing, for example, narcotics, constitutes a problem. The paper ends with a discussion of some suggestions about how to distinguish between those enhancements that are health related and those that are not. One plausible idea holds that an enhancement is health related when the substance, or aid, increases ability or well-being, is integrated into the body, and does not harm the individual’s fundamental health. (shrink)

This article analyzes appropriate public policies for enhancement use of two most important stimulant drugs: Ritalin (methylphenidate) and Adderall (mixed amphetamine salts). The author argues that appropriate regulation of cognition enhancement drugs cannot be a result of a general discussion on cognitive enhancements as such, but has to be made on a case-by-case basis. Starting from the recently proposed taxation approach to cognition enhancement drugs, the author analyzes available, moderately permissive models of regulation. After a thorough analysis of relevant (...) characteristics of methylphenidate and amphetamine, the author concludes that a moderately liberal permissive regulation of enhancement use by healthy adults might be appropriate for extended release forms of methylphenidate. However, due to their danger profile, amphetamine and instant release forms of methylphenidate should not be made readily available to healthy adults and would need to be prohibited. (shrink)

Developments in neuroscience have raised the possibility that pharmaceuticals may be used to enhance memory, mood, and attention in people who do not have an illness or disorder, a practice known as “cognitive enhancement.” We describe historical experiences with two medicinal drugs for which similar enhancement claims were made, cocaine in the late 19th and early 20th centuries, and amphetamines in the mid 20th century. These drugs were initially introduced as medicinal agents in Europe and North America before becoming more (...) widely used for a variety of purposes, including what would nowadays be considered cognitive enhancement. Their trajectory of use conformed to the typical use cycle of psychotropic drugs. There was an initial steep rise in prescribing for medical use, followed by expanded nonmedical use that was fueled by enthusiasm for the drugs’ effects. As the number of regular users increased, problems related to use (such as addiction) became apparent, societal concern increased, and laws were passed banning nonmedical use and eventually, medical use. This historical experience draws attention to the adverse side effects of enhancement use that only become apparent with regular, wide-scale use of a drug. We highlight the similarities between the enthusiasms for cocaine and amphetamines and the current enthusiasms for using prescription stimulants for cognitive enhancement. We argue bioethicists should not encourage the cognitive enhancement use of drugs such as methylphenidate in the absence of evidence on the efficacy and safety of their use for cognitive enhancement purposes. (shrink)

In my target article, I analyzed available information and policy options for the two of the most commonly used cognitive enhancement (CE) drugs: Adderall and Ritalin. I concluded that for all forms of amphetamine, including Adderall, and for instant-release forms of methylphenidate, any form of sale beyond prescription for therapeutic purposes needs to be prohibited, while some form of a taxation approach and the economic disincentives model (EDM) in particular could be an option for public policy on extended-release forms (...) of methylphenidate . However, there has been a considerable amount of constructive criticism regarding my proposal. Some neuroethicists objected to my favoring prohibitive policies to dangerous CE drugs such as amphetamine and argued for laissez-faire or even mandatory use of enhancements. Others took issue with the conclusion that the economic disincentives model (EDM) could be an option for public policy on extended release forms of methylphenidate. Furthermore, there are those that think my argument in general and EDM in particular are failing to address the relevant issues in regulation of CE, such as social justice and real autonomy. Finally, there are those who offer suggestions on how the argument and the model of public policy for CE drugs can be improved. These comments are greatly appreciated, and I hope that my responses have captured the issues they were concerned with. (shrink)

The stimulant “benefits” of amphetamine and its derivative, methamphetamine, have endured since the drugs first became popular nearly a century ago. The concepts of increasing energy for functional purposes related to work and productivity have been well studied. However, the broader idea of increased alertness, and what this means in the lives of users, has not yet been sufficiently examined. This article draws from ongoing research with active methamphetamine users to explore the perceived benefits, drawbacks, and meanings of remaining (...) alert—awake and vigilant—while most of the world sleeps. The experiences of several users are situated in the contexts of sociostructural and mental health issues that shape cycles of use and meanings of addiction. (shrink)

The Iowa Gambling Task (IGT) is widely used to study decision‐making within healthy and psychiatric populations. However, the complexity of the IGT makes it difficult to attribute variation in performance to specific cognitive processes. Several cognitive models have been proposed for the IGT in an effort to address this problem, but currently no single model shows optimal performance for both short‐ and long‐term prediction accuracy and parameter recovery. Here, we propose the Outcome‐Representation Learning (ORL) model, a novel model that provides (...) the best compromise between competing models. We test the performance of the ORL model on 393 subjects' data collected across multiple research sites, and we show that the ORL reveals distinct patterns of decision‐making in substance‐using populations. Our work highlights the importance of using multiple model comparison metrics to make valid inference with cognitive models and sheds light on learning mechanisms that play a role in underweighting of rare events. (shrink)

There is a long history and growing evidence base that the use of drugs, such as anabolic-androgenic steroids, to enhance human performance is common amongst armed forces, including in Australia. We should not be surprised that this might have occurred for it has long been predicted by observers. It is a commonplace of many recent discussion of the future of warfare and future military technology to proclaim the imminent arrival of Super Soldiers, whose capacities are modified via drugs, digital technology (...) and genetic engineering, in ways that increase their performance exponentially. This is what some observers have referred to as the “Gladiator Model” wherein the aim is to create soldiers able to perform feats of which ordinary citizens are not capable. One key aspect of this “gladiator project” is the use of illicit drugs to enhance performance. Could we use drugs, such as steroids or amphetamines, to enhance performance? Should we use such drugs? In this paper we explore the ethics of creating Super Soldiers, and raise issues of consent, coercion and the extent to which such use is permitted or condemned by just war theory. We conclude that much will depend on the extent to which such use is harmful to the soldiers themselves and this is still an open question. (shrink)

Jean-Paul Sartre is an undisputed giant of twentieth-century philosophy. His intellectual writings popularizing existentialism combined with his creative and artistic flair have made him a legend of French thought. His tumultuous personal life - so inextricably bound up with his philosophical thinking - is a fascinating tale of love and lust, drug abuse, high profile fallings-out and political and cultural rebellion. This substantial and meticulously researched biography is accessible, fast-paced, often amusing and at times deeply moving. Existentialism and Excess covers (...) all the main events of Sartre's remarkable seventy-five-year life from his early years as a precocious brat devouring his grandfather's library, through his time as a brilliant student in Paris, his wilderness years as a provincial teacher-writer experimenting with mescaline, his World War II adventures as a POW and member of the resistance, his post-war politicization, his immense amphetamine fueled feats of writing productivity, his harem of women, his many travels and his final decline into blindness and old age. Along the way there are countless intriguing anecdotes, some amusing, some tragic, some controversial: his loathing of crustaceans and his belief that he was being pursued by a giant lobster, his escape from a POW camp, the bombing of his apartment, his influence on the May 1968 uprising and his many love affairs. Cox deftly moves from these episodes to discussing his intellectual development, his famous feuds with Aron, Camus, and Merleau-Ponty, his encounters with other giant figures of his day: Roosevelt, Hemingway, Heidegger, John Huston, Mao, Castro, Che Guevara, Khrushchev and Tito, and, above all, his long, complex and creative relationship with Simone de Beauvoir. Existentialism and Excess also gives serious consideration to Sartre's ideas and many philosophical works, novels, stories, plays and biographies, revealing their intimate connection with his personal life. Cox has written an entertaining, thought-provoking and compulsive book, much like the man himself. (shrink)

The article explores some of the issues that have arisen in the discourse on pharmaceutical cognitive enhancement (PCE), that is, the use of stimulant drugs such as methylphenidate, amphetamine and modafinil by healthy individuals of various populations with the aim of improving cognitive performance. Specifically, we explore the presumed sizes of existing PCE user populations and the policy actions that have been proposed regarding the trend of PCE. We begin with an introductory examination of the academic stances and philosophical (...) issues involved in defining PCE. We then focus on an examination of the population sizes of presumed current PCE users that have been listed in the academic literature on PCE, on presuppositions, which have been problematized by some authors as based on anecdotal or misinterpreted survey data. We follow this with an empirical examination of a potential PCE user population in a national context (students at the University of Ljubljana in Slovenia). We then proceed to examine the regulatory options proposed in the academic literature to address PCE, finally comparing them with an empirical overview of the policy recommendations on PCE produced in the multinational context of several national ethics advisory bodies (EABs) in Europe. Our main conclusion is that there is still little debate among the national EABs on what type of public policy responses, if any, are needed to address PCE in European countries, and that the issues they do address are similar to those discussed and proposed in the academic articles on PCE. (shrink)

This commentary compares clinical aspects of ketamine with the amphetamine model of schizophrenia. Hallucinations and loss of insight, associated with amphetamine, seem more schizophrenia-like. Flat affect encountered with ketamine is closer to the clinical presentation in schizophrenia. We argue that flat affect is not a sign of schizophrenia, but rather, a risk factor for chronic schizophrenia.

Academic performance enhancement or cognitive enhancement (CE) via stimulant drug use has received increasing attention. The question remains, however, whether CE solely represents the use of drugs for achieving better academic or workplace results or whether CE also serves various other purposes. The aim of this study was to put the phenomenon of pharmacological academic performance enhancement via prescription and illicit (psycho-) stimulant use (Amphetamines, Methylphenidate) among university students into a broader context. Specifically, we wanted to further understand students’ experiences, (...) the effects of use on students and other factors, such as pressure to perform in their academic and private lives. (shrink)

The statistics at least seem alarming. The production of Ritalin, an amphetamine derivative used for the treatment of attention deficit disorder in children (and lately, in adults as well), has risen a whopping 700 percent since 1990. According to figures given by Lawrence Diller in Running on Ritalin, over the decade, the number of Americans using Ritalin has soared from 900,000 to almost 5 million -- the vast majority children from the ages of 5 to 12, though there is (...) a significant rise in Ritalin use among teens and adults as well. No comparable rise is reported in other countries, though a much smaller surge has taken place in Canada and Australia. In Virginia Beach, Virginia (perhaps the most egregious example), 17 percent of fifth-grade boys were taking Ritalin in 1996 to control behavior problems and improve school performance. (Boys on Ritalin 1 outnumber girls in a ratio of 3.5 to 1; when I was recently complaining to another mother about my own son's academic difficulties, she said simply, "Welcome to the world of boys.") Stimulants have been used to treat behavior problems in children since 1937; Ritalin itself appeared on the market in the 1960s to treat what was then called "hyperactivity" -- impulsive, disruptive behavior by children who just "couldn't sit still." In recent years, however, the root problem has been identified as "attention deficit disorder" (ADD), either with or without attendant hyperactivity. Symptoms of ADD, according to the standard survey used in its diagnosis, include: "often fails to give close attention to details or makes careless mistakes in schoolwork," "often has difficulty organizing tasks and activities," and "often avoids, dislikes, or is reluctant to engage in tasks that require mental effort (such as schoolwork or homework)." Symptoms of ADD-H (the variant with hyperactivity) include: "often fidgets with hands or feet or squirms in seat," and "often has difficulty playing or engaging in leisure activities quietly." Ritalin, by most accounts, is remarkably effective in getting such children to settle down and pay attention, with resultant (at least short term) gains in parental sanity and academic achievement. The fear, stated quite baldly, is that as a society we are 1 drugging our children in ever-larger numbers to get them to conform to adult expectations.. (shrink)

Pike, Gregory K Drug abuse has come into the public spotlight again as the Australia21 group recently released several documents arguing for an end to the prohibition of drugs like cannabis, heroin, cocaine, ecstasy and amphetamine. The arguments are not new, and those who advance them probably think it is only a matter of time before they achieve their goal.

In lieu of an abstract, here is a brief excerpt of the content:When Is Enough, Enough?Megan HomsyThis was a case that stuck with many members of our transplant team for a long time. The patient was a 44-year-old Caucasian male evaluated for a liver transplant with a diagnosis of hepatitis C virus (HCV), originally diagnosed 11 years before the transplant evaluation. The patient met the criteria for the following substance use diagnoses: alcohol use disorder moderate in sustained remission, in a (...) controlled environment, opioid use disorder, severe, in sustained remission, on maintenance therapy, in a controlled environment, stimulant use disorder, amphetamine-type, severe, in early remission, in a controlled environment and stimulant use disorder, cocaine-type, severe in early remission, in a controlled environment.The patient had been living in a sober living housing program for approximately ten months prior to his transplant evaluation with me, his social worker. He had also been diagnosed with depression and bipolar disorder. He had been intermittently linked with mental health services and had participated in numerous detox and substance abuse programs over the last ten years, with varying degrees of success. He was in dual diagnosis treatment (i.e., treatment for co-occurring substance use and mental health disorders) through his Suboxone clinic and was completing toxicology screenings on a biweekly basis.After concluding the minimum three months of drug and alcohol treatment set forth by the state's Organ Transplantation Consortium, the patient graduated from his sober living program, moved in with his sister, and was listed for a liver transplant.The patient was transplanted five months after his clinic evaluation. At the time of the surgery, the patient's Suboxone was abruptly discontinued and replaced with IV Dilaudid. Within days of his transplant, the patient frequently expressed concerns about his pain. Several medical services attempted to manage the pain medications, resulting in his pain management plan being changed repeatedly and much confusion over his current medication regimen. During his liver transplant hospitalization, the RN found the patient with a needle in his arm, and after a search of the patient's hospital room, the hospital police found drug paraphernalia and illicit substances. The patient was eventually discharged to an inpatient substance abuse program, which he left before completing the program and against medical advice.During his first year post-transplant, I attempted to arrange other various treatment programs for him (most of which he did not follow through with) and to find housing for him (as he had been forced to leave his sister's home after his relapse). Eventually, the patient was incarcerated on drug-related charges. Numerous times, the patient missed completing his labs and his post-transplant appointments. He did not refill his immunosuppressant medications, and for lengthy periods of time, he was unreachable by the transplant care team, which resulted in my team members and I calling the patient's family, other providers, and the police for safety checks.In the aftermath of these issues, my colleagues and I had to reckon with the realization that we had failed the patient. As a team, our transplant center created a task force to review this case and what to do in the future to prevent such breakdowns in patient care. We created protocols for managing patients who, at the time of their transplant, are on Medication Assisted Treatment (MAT) such as Suboxone and methadone. Staff across the multidisciplinary team attended trainings regarding addiction, pain management, and best practices for MAT services. Additionally, our transplant center collaborated with our hospital's addiction treatment program for a streamlined referral process for transplant patients to addiction services.This patient's case and its sensational nature resulted in many conversations, both professional and unprofessional. Members of the social worker department became aware that personnel within transplant, though not involved in patient care, were inappropriately discussing this patient's case and engaging in unprofessional behavior. Said actions led to the termination of a member of the transplant team. I was placed in the unenviable [End Page E3] position of having to report this behavior to hospital management and legal teams to protect a vulnerable patient.The ethical challenge behind this case really stems from the transplant team attempting to balance two... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Transformation:Power in Persistence and PerspectiveTyler BendrickWe've got another meth napper," my resident stated. With an introduction like that, it is hard not to be immediately labeled as a "difficult patient." Being the only Spanish-speaking person on the team, I, a third-year medical student, became the primary point of contact for this severely injured patient. He was an only-Spanish-speaking, 36-year-old male admitted [End Page 7] to our trauma service (...) after he was hit by a truck while riding his bicycle. Unbeknownst to me at the time, the 14 days I spent caring for this man would become one of the most pivotal learning experiences of my medical school career. It changed not only how I understand and approach "difficult patients" but expanded my knowledge of the complexities and challenges of the current healthcare system and how we, as physicians and healthcare providers, can deliver the best care to patients with low health literacy and limited resources.So, what is a "meth napper?" I questioned. "Well, meth is a super stimulant," my resident explained. "When people are frequent meth users, they get used to functioning normally with high levels of stimulants in their body, reducing the normal regulation of wakefulness. When the amphetamine is removed (such as upon admission to the hospital), the body is left to fend for itself, and thus patients oftentimes sleep for 23 hours a day for about 3 to 5 days while their body works to detox and normalize hormones."As predicted, my new friend, "Joe," was napping when I first went to see him. Thinking back, the word "napping" does not accurately describe his level of somnolence. He was virtually unarousable, and I took to a sternal rub to wake him up at 5 a.m. after his traumatic exploratory laparotomy the night before. Once aroused, he was furious. "Estoy bien. Tengo dolor y tengo hambre," he grunted at me. (I am fine, and I am in pain and hungry!). "Ok, Joe," I replied in Spanish, "I am just going to do a quick exam and you can go back to sleep. We will give you medications for your pain. You had a big surgery on your intestines, so you cannot eat or drink right now. If everything goes well in the next couple of days and you start walking around, we can advance your diet." He begrudgingly let me examine him, never opening his eyes, and I left and went about my day.We continued this routine for five days. I would periodically check on him and usually found him sleeping. When awake, he refused to work with physical therapists, get up and walk or go to the bathroom, shower, use his spirometer, or converse with the nursing staff. He seemed completely disinterested in recovery. About day three, we slowly advanced his diet to clear liquids so he could quench his thirst. Sometimes his wife was there, and she would ask for updates, to which I could only reply, "We have to wait until he is more awake or willing to work with us." I was getting frustrated, as it seemed that his noncompliance was becoming his barrier to discharge.But on day six, everything changed. I went to check on Joe, and he was wide awake, vomiting, and irate. He shouted that he was in incredible pain, and his incision was wet. He was also complaining that he had not eaten in five days, and was insisting that we were starving him. Again, I calmly explained (as I had multiple times a day for the past five days) that his major abdominal surgery prevented us from feeding him until his intestines healed. We were giving him fluids and nutrition through his IV lines, so he was not starving to death. I rushed to get my resident to examine his oozing wound, and after a CT scan and an x-ray, we discovered what we feared: His wound had opened down to the fascia, "dehiscence," as it is called. On top of this, he now had a bowel obstruction, causing his vomiting. His lack of mobility for the past five days had slowed his... (shrink)

Addiction is compulsive need for and use of a habit-forming substance. It is accepted as a mental illness in the diagnostic nomenclature and results in substantial health, social and economic problems. In the diagnostic nomenclature, addiction was originally included in the personality disorders along with other behaviours considered deviant. But it is now considered a clinical syndrome. Addiction is multifactorially determined, with substantial genetic influence. The development of addictions is also influenced by environmental factors, and an interplay between the two. (...) In the clinical context, addiction puts problem substance use on the agenda, and helps focus on the difficulties associated with drug use. But the concept of addiction is also used to distance the user from addicts, and in this way, may be counter-therapeutic. The addiction concept has also had a substantial influence on policy. The almost universal prohibition against drugs such as opiates, cocaine, cannabis and amphetamine has much support. But unfortunately, it has not been able to hinder the development of substance use problems. Optimism is fostered by the development of respectful ways of thinking about people with addictions, in particular, from advocates of motivational interviewing. (shrink)